LAW ENFORCEMENT/COURT REFERRAL FORM MISDEAMENOR CHARGES ONLY

Referral Date: Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively

Case or Docket #: This field is required

Charge(s): This field is required

Additional Charge: This field is required

Youth's Name This field is required

Gender This field is required

Date of Birth: Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively

Parent/Guardian Name: This field is required

Relation to Youth: This field is required

Address: This field is required

Phone Number: Format must be 123-123-1234. This field is required.

Email: Please provide a valid email address

Primary Language other than English: Yes No Please select at least one option

If yes, please specify other language(s):

Family Notified of Referral? Yes No Please select at least one option

If no family contact has been made, please specify the reason:

DCFS or OJJ involved with the Youth? Yes No Please select at least one option

If yes, please specify

Additional Comments or Concerns:

Referral Agency: This field is required

Name: This field is required

Phone Number: Format must be 123-123-1234. This field is required.

Contact Email: Please provide a valid email address